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No added benefit beyond 30 days with enoxaparin after fibrinolysis for STEMI

Clinical Question:
Does the use of enoxaparin as compared with unfractionated heparin after fibrinolysis for ST-segment elevation myocardial infarction improve long-term mortality and morbidity?

Bottom Line:
Although a previous study showed that the use of enoxaparin as compared with unfractionated heparin (UFH) decreases short-term risk of death or myocardial infarction in patients with ST-segment elevation myocardial infarction (STEMI) who receive fibrinolysis, there is no additional benefit beyond the initial 30 days. (LOE = 1b)

Reference:
Morrow DA, Antman EM, Fox KA, et al, for the ExTRACT-TIMI 25 Investigators. One-year outcomes after a strategy using enoxaparin vs. unfractionated heparin in patients undergoing fibrinolysis for ST-segment elevation myocardial infarction: 1-year results of the ExTRACT-TIMI 25 trial. Eur Heart J 2010;31(17):2097-2102.  [PMID:20400762]

Study Design:
Randomized controlled trial (nonblinded)

Funding:
Industry

Allocation:
Concealed

Setting:
Inpatient (any location) with outpatient follow-up

Synopsis:
Previous data from the ExTRACT-TIMI 25 trial showed reduced 30-day risk of death or myocardial infarction with the use of enoxaparin as compared with UFH following fibrinolysis for STEMI. In this industry-sponsored trial, investigators report 1-year outcomes of the 2 strategies. Adults presenting with STEMI within 6 hours of symptom onset without contraindication to fibrinolysis, hemodynamic instability, or known renal insufficiency were eligible. All participants were treated with aspirin and a fibrinolytic, followed by either UFH (n = 10,122) or enoxaparin (n = 10,153) for a minimum of 48 hours until completion of successful coronary revascularization, hospital discharge, or a maximum of 8 days. The 2 groups were well balanced at baseline. Patients had a median age of 59 years and 75% were male. Analysis was by intention to treat, and follow-up through 1 year was available for 99% of the group. The primary end point of death or nonfatal recurrent myocardial infarction at 1 year was reduced with the use of enoxoparin as compared with UFH (15.8% vs 17.0%; hazard ratio = 0.92; 95% CI, 0.86-0.98; P = .01). However, this was primarily driven by a reduction in recurrent myocardial infarction with no difference in mortality at 1 year. Additionally, analyses from 30 days to 1 year revealed that reduction in both death and myocardial infarction occurred early on with no additional benefit after the initial 30-day period.

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